“Forks Over Knives” - Lee Fulkerson (2011)

The documentary film Forks Over Knives (2011) is dedicated to convincing its audience that adopting a whole foods, plant-based diet is the most important act we can take to ensure good health and combat disease.  This is more than just an “eating healthy food is good for you” message, which many people will noddingly accept, but which will have little impact on their everyday eating habits.  After all, everyone already knows that eating food is a key activity in our daily lives, and most people who are presently in reasonably good health already think that their eating habits are within the boundaries of normalcy.  Why should they suddenly be converted to what seems like a strict dietary regimen, especially when everyone else they see around them eats the way they do?

Nevertheless, this film seeks to convince its likely reluctant viewing public that adopting a plant-based (i.e. vegan) diet is not just a good idea, but is of crucial, life-saving importance for everyone.  In particular, the producers of this film argue that by so doing, one can actually reverse the progress of many serious degenerative diseases, including coronary heart disease.  In this respect Forks Over Knives has a similar message to Mike Anderson’s Eating, 3rd Edition (2009), and because of the overlapping of themes, I suggest that readers examine my earlier review of that film for additional commentary. 

Actually, comparing those two similarly-themed films highlights a fundamental issue of documentary film presentation.  If you seek to convince your audience concerning the truth of some proposition, what is better – exposition or narrative?  We know that presenting a convincing logical argument is important, but we also know that telling stories that captivate the viewer are even more important.  Each of these films follows both of these two paths, but Eating, 3rd Edition is probably more oriented towards the emphatically asserted logical argument side of things, while Forks Over Knives, leans more in the direction of story-telling to make its points.

In fact Forks Over Knives follows a number of stories in parallel, switching back and forth among them.  Two of the stories trace the distinguished careers of two important nutrition professionals: 
  • Dr. Caldwell Esselstyn, a physician in the field of cardiology and the author of the book Prevent and Reverse Heart Disease (2007) [1].
  • Professor T. Colin Campbell, a nutritional biochemist at Cornell University and author of the book, The China Study (2004) [2].
Both of them grew up on farms and followed traditional meat-and-dairy-based diets during their early years, but eventually their separate professional experiences provided them with the empirical evidence to change their minds about that diet. 

Interleaved with the stories about the two specialists are several other stories about ordinary people who adopt plant-based diets on the recommendation of their personal physicians [3]. The people in these secondary stories already have significant health problems to begin with, and this includes a group of 17 people with very serious cardiac problems who were placed under the Dr. Esselstyn’s care.  An additional, originally unplanned patient is the film’s writer-director, Lee Fulkerson, who volunteered to have himself medically assessed and was told that many of his health indicators (blood pressure, blood cholesterol level, etc.) were dangerously high.  These patients were not given any medications [4]; they were all just instructed to follow a rigorous plant-based diet prescribed by their doctor. Over the course of several months that the film was in production, all of them showed dramatic improvements in their bio-indicators and general health.

Such human-interest stories may give a personal touch to the film, but to me, they are not as interesting or convincing as the more evidence-based accounts associated with the work of Drs. Campbell and Esselstyn.  Individual testimonials, which are the stock and trade of infomercials, are an easy sell, and one should always be cautious about making generalizations from them.  In fact food faddists, like Robert Atkins and Adelle Davis, have long been popular with the general public and perennially top bestseller charts, but any evidence concerning the effectiveness of their approaches has always been scanty.  Atkins advocated a high-fat, low-carbohydrate diet, while Davis promoted a high-protein breakfast diet, but both of their dietary regimes are now discredited.  The fact that they had large followings was probably attributable to the fact that people who follow any prescribed diet are likely to lose weight – simply because the more limited food options on any diet lead to a reduction in snacking and overall food consumption.

The problem with nutrition science is that the field is immensely complicated, and even though new discoveries are regularly being made, we are still only at the doorstep of knowing the intricacies of how food intake affects health.  For example although vitamins have been identified as essential nutritional ingredients, it seems that there are associated, but not well understood, micronutrients coexisting with these vitamins in nature that are needed for these vitamins to be properly absorbed and processed in the body.  Animals evolved in the wild to digest and process these foods that included the associated micronutrients along with the vitamins and caloric food elements.  So if a person takes vitamin tablets, these micronutrients are mostly absent, and the benefits from the vitamins are likely to be reduced.  

Because the field of nutritional science is so complicated, medical schools give their students little, if any, training concerning nutrition. This leaves doctors will little option other than to repeat the mantras that are endlessly repeated by the meat-and-dairy industry advertisements claiming that
  • meat is the most essential food, because it is rich in protein and we are mostly made up of protein, and
  • milk (from dairy cows) is equally essential because it is rich in calcium, which is needed for strong bones.
So most people, as the film suggests via on-the-street interviews, don’t question these ideas.  But Colin Campbell shows that these statements are misleading (see below).

Of course, the meat-and-dairy industry has a vested interested in getting people to consume their products, and so they spend vast sums of money in advertising and use their political muscle to lobby for government subsidies in order to further their aims.  And they convince a lot of people: the film shows Connie Diekman, a past president of the American Dietetic Association (now the Academy of Nutrition and Dietetics), who espouses the virtues of meat protein and cow’s milk. In fact Forks Over Knives has some interesting material from Dr. Neal Barnard, the head of Physicians Committee for Responsible Medicine, concerning the disturbing influence the meat-and-dairy industry has on the US Department of Agriculture's recommendations for dietary health.  Many of the USDA's specialist advisers are under the pay of the meat and dairy industry.  In particular, he discusses how big agribusiness in the US manages to get government subsidies to provide cheese, meat, and milk products to school children.

There are very few people who are in a position to counter the meat-and-dairy propaganda with objective evidence, particularly given the inherent complexity of the nutrition field.  Nevertheless, even if the nutrition field is extraordinarily complex at the biochemical level of causality, one can still pursue a scientific path of investigation at the higher level of human health outcomes.  This is the path that Drs. Campbell and Esselstyn pursued in their separate ways: one based on epidemiological research and the other on clinical practice.

The journey of Caldwell Esselstyn, a Yale graduate and former Olympic rowing champion, to arrive at an understanding of animal-based foods' harmful effects is based on his long-term clinical experiences. He first began to realize the problem when he learned that during the German occupation of Norway, when the German army confiscated the local pastoral animals to feed their own troops, the Norwegian mortality from circulatory diseases was dramatically reduced. After the war, when the Norwegians returned to their carnivorous diet, the mortality from circulatory diseases returned to prewar levels.  Inspired by this evidence, Esselstyn has gone on to reverse the degenerative progression of coronary heart disease in his many (several hundred) patients by prescribing strictly plant-based diets.  As a doctor, he is frustrated how our modern diet needlessly harms us: every year there 500,000 Americans who undergo heart bypass surgery, at a cost of $100,000, not to mention the hundreds of thousands of people who die of heart attacks annually.  Almost all of this could be avoided if people were to follow a plant-based diet.  According to his biomedical explanation, animal foods cause the deterioration of endothelial cells that line the blood vessels and maintain appropriate blood flow. As these endothelial cells are damaged, a person is more at risk of a heart attack.   But, interestingly, a plant-based diet can actually lead to the restoration of these endothelial cells in the blood vessels, and therefore a plant-based diet can actually reverse the course of coronary heart disease.

Dr. Campbell’s journey followed a different path – that of a biochemical researcher.  He was one of the leaders of the China-Cornell-Oxford project, which was a large observational study of health outcomes in rural China during the 1980s.  This study covered a large area of China that included variously different diet practices.  But an important advantage of this sampling was that the genetic pool of all these people were very similar – Chinese Han people.  So this made comparisons across the other factors largely independent of genetic variations.  In addition, since the study concentrated on rural populations, it examined populations that were generally stable and unchanging over decades of time.   Thus the size, scope, and advantageous characteristics of the study were unprecedented.  The results of the study were published in Campbell’s book, The China Study (2004).  This is a fascinating book and well worth reading the whole thing, not just a summary.

Campbell and his team in The China Study examined 367 diet and health-related variables across 65 counties in China, in each of which 100 people were randomly selected for investigation.  This led to 94,000 correlations between diet and disease, and Campbell’s team found about 9,000 of these correlations to be statistically significant.  The most important conclusion they came to was that a plant-based diet is correlated with lower incidences of cancer, stroke and coronary heart disease. This association between disease and animal-based food extended even into very low percentages of animal-food consumption: the less animal-based food consumed, the better the health outcomes.

Campbell’s studies also showed that the two meat-and-dairy industry mantras about protein from meat and calcium from milk were fundamentally misleading. The fact that a plant-based diet supplies an adequate amount of protein seems to be little known among the general public, and few people know, for example, that  broccoli has double the protein per calorie that beefsteak has.  Moreover, Campbell remarks that animal protein creates a condition in the body called, “metabolic acidosis”.  To combat this condition, the body draws on its most readily available acid buffer: calcium from the bones. Low-fat milk makes this situation even worse, because with lower fat, the protein becomes a larger proportion of the total (not to mention the fact that low-fat milk is correlated with prostate cancer, according to Campbell).

There is also a small feature in the film discussing Dr. John McDougall’s clinical work that suggests a vegan diet can reverse the course of breast cancer.   This includes an interview with role model Ruth Heidrich, who attributes her survival from breast cancer to her vegan diet.  Even now in her seventies, she  is still participating in triathlon competitions.

Why is it so difficult to change public behaviour on an issue that seems as though it would be clear cut?  People imagine that it would be much too difficult to give up meat and milk, but it really isn’t that hard.  It might be helpful to compare the issue of eating meat with smoking.  I have not found very reliable statistics, but it is generally believed that during the during the 1950s, more than 50% of men smoked and more than 50% of doctors smoked [5].  There is even one figure that states that in 1951, 87% of British doctors smoked.  How could this be, when doctors even then had information that smoking was harmful to human health?  It seems that many of doctors, just like everybody else, found it too difficult to follow an independent path on this score. But when the US Surgeon General’s report appeared in 1964 connecting smoking with lung cancer, there was a dramatic reduction in the number of doctors who smoked. Since then smoking has gradually come down, across the board.  And you don’t find many doctors smoking these days.  Some day the same change may come about in connection with eating meat and dairy products.

I have remarked previously about the four main spheres of increasingly more personal interactive compass that underlie why you should be vegetarian:
  1. World. It takes more than ten times both the land acreage and energy from fossil fuels to produce a calorie from animal food than from plant-based food.  We are currently facing a worldwide food crisis due to the use of land and water resources devoted to animal farming. The world’s cattle alone eat enough grain to feed 8.7 billion people. If humans consumed a plant-based diet, there would be no such crisis. In addition, animal farming contributes significantly to global-warming gas production, particularly methane, which has more than twenty times the impact on global warming than does CO2.
  2. Community. Every year roughly 50 billion animals are slaughtered for human consumption. Yet animals are sentient beings like us that feel pain. They are existentially our brothers and sisters and do not deserve to be killed for our pleasure.
  3. Body. As outlined in this film, a diet with more than a tiny amount of animal-based food (meat and dairy) is very harmful to human health.
  4. Soul. Most small children are instinctively alarmed when they first learn that they are eating flesh from dead animals, but adults persuade them to accept it. That initial alarm that you felt back then was the voice of your inner soul – the essential core being who you really are. When you resolve to give up eating animal-based food, you are responding to that inner voice and following the path of your true, compassionate nature. You are becoming the complete person that you have always wanted to be.
Forks Over Knives, like Eating, 3rd Edition, covers the first three points, but focuses primarily on the third point.  Earthlings (2005), focuses on the second point.  Most people become vegetarians or vegans (for example former US President Bill Clinton, who was influenced by The China Study) from considerations made by the third point.  Others, like film director James Cameron, are primarily moved by the second point.  But in the end, it is the fourth point that will be the most important for you.  Each person, like Drs. Esselstyn and Campbell, can have his or her own journey down this path.  If you have not begun this journey, Forks Over Knives is your invitation to join it.

  1. Esselstyn, C. B., Prevent and Reverse Heart Disease, (2008), Avery Trade.
  2. Campbell, T. Colin, and Campbell, Thomas M., The China Study (2004),  BenBella Books.
  3. These physicians are Dr. Esselstyn and Dr. Matt Lederman.
  4. Dr. Esselstyn’s patients were originally given cholesterol-lowering medications, but I believe that now their only treatment is to have a plant-based diet.
  5. Smith, Derek, Tobacco Induced Diseases (2008), 4:9 doi:10.1186/1617-9625-4-9, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2556033/

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